research leadership in the clinical environment

RESEARCH LEADERSHIP IN

THE CLINICAL ENVIRONMENT

A/Professor Margaret Fry

Director Research and Practice Development NSLHD

Faculty of Nursing, Midwifery and Health

University of Technology, Sydney

The forces and drivers active currently

within Health Services and Practice

New Directives Guidelines GL2012_004

Perform in a clinical leadership role evidenced by participation in

practice development activities, including mentoring, education,

active participation in communities of practice, policy development,

research and quality improvement (point 5 pg 7)

2

The forces and drivers active currently

within Health Services and Practice

Understanding the context

External drivers

Government Policy, Government focus, population focus, new

models of care

Internal drivers

Clinical needs, performance targets, IIMS, workforce issues,

budget, service delivery

Staff behaviour drivers

Values, beliefs, attitudes, motivation

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The forces and drivers active within

Health Services and Practice

4

Examining and Exploring Practice

Clinical Inquiry:

Do we have what we think we should have to deliver services?

(resources, staff, knowledge, skills…?)

Are we doing what we (know we) ought to be doing? (are our care

processes aligned with „best practice‟?)

Are our patient outcomes as good as the evidence shows they can

be? Peer benchmarking; research evidence?

5

Audits: Structure, Process, Outcome

Clinical audits are a quality improvement process that seeks to improve

patient care and outcomes through systematic review of care against

explicit criteria and the implementation of change.

Aspects of the structure, processes, and outcomes of care are selected

and systematically evaluated against explicit criteria.

Outcome of audit: changes are implemented at an individual, team, or

service level and further monitoring is used to confirm improvement in

healthcare delivery.

(National Institute for Clinical Excellence)

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Audits: Structure, Process, Outcome

Structures/ resources:

Do clinicians have adequate knowledge/skills?

Processes:

Effective discharge screening systems? Care planning process?

Referral processes?

Outcomes:

Pain management, QoL, reduce LOS, reduce re-admission, staff

satisfaction

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Research Leadership in Health Services

and Practice

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Surveys, Observation of practice, Interviews

Extraction from other forms of existing data – EMR, pharmacy,

pathology, imaging, PACE records, IIMS, any HIE data…

Documentation reviews – case notes, management plans, observation charts,

medication charts ……


and Practice

What are your service targets/goals ?

Gap analysis:

Awareness

Knowledge

Implementation

Values and commitment

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Research Leadership in Health Services and Practice

How is pain managed in our ED?

Fry, M.., Holdgate, A., Baird, L., Silk, J., & Ahern, M. 1999, "An emergency department's analysis of pain management patterns", Australian Emergency Nursing Journal, vol. 2, no. 13, pp. 31-36.

Fry, M. Holdgate A. 2002; Nurse initiated intravenous morphine in the emergency department: efficacy, rate of adverse events and impact on time to analgesia. Emergency Medicine 14(3):249-254.

Fry, M. Ryan, J.; and Alexander N 2004 Prospective Study of Nurse Initiated Panadeine Forte: Expanding Pain Management in the ED. Accident & Emergency Nursing 12(3):136-140.

Fry, M. Arendts, G. 2006 Factors Associated with Delay to Narcotic Analgesia in Emergency Departments. The Journal of Pain, 7(9) pp 682-686.

Can nurses improve waiting times ?

Fry, M. & Rogers T. Fry, M. & Rogers T. 2009 The Emergency Transitional Nurse Practitioner role: implementation study and preliminary evaluation Australasian Emergency nursing Australasian Emergency nursing In Press

Fry, M. Borg, A., Jackson, S., & McAlpine, A. 1999, "The advanced clinical nurse a new model of practice: meeting the challenge of peak activity periods", Australian Emergency Nursing Journal, vol. 2, no. 3, pp. 26-28.

Fry, M. & Jones K 2005 The clinical initiative nurse: Extending the role of the emergency nurse, who benefits?, Australian Emergency Nursing Journal 8(1-2): 9-12.

Who are the patients leaving prior to medical assessment?

Fry, M. Thompson, J.; Chan, A. 2004,Patients Regularly Leave Emergency Departments Before Medical Assessment: A Study of Did Not Wait Patients, Medical Profile and Outcome Characteristics. AENJ 6(2): 21-26. 10

Research Leadership in Health Services and

Practice Do Nurse Practitioners make a difference? Fry, M. and T. Rogers (2009). "The Transitional Emergency Nurse Practitioner role: implementation study

and preliminary evaluation." Australasian Emergency Nursing Journal 12(2): 32-37.

Fry, M., J. Fong, et al. (2011). "A 12-month evaluation of the impact of Transitional Emergency Nurse

Practitioners in one metropolitan Emergency Department." Australasian Emergency Nursing Journal

14(1): 4-8.

Luttze, M., A. Ratchford, et al. (2011). "A review of the Transitional Emergency Nurse Practitioner."

Australasian Emergency Nursing Journal 14: 226-231.

Fry M. A systematic review of the impact of afterhours care models on emergency departments,

ambulance and general practice services. Australasian Emergency Nursing Journal. 2011;14:217-25.

Fry M. Literature Review of the Impact of Nurse Practitioners in Critical Care services Nursing in Critical

Care. 2011;16(2):58-66.

What is the best technique for venipuncture?Dwyer, D., Fry, M., Sommerville, A., & Holdgate, A. 2006 A randomised, single blinded control trial of haemolysis rate comparing two cannula aspiration techniques. Emergency Medicine, 18(5/6), pp. 484-487.

The need to develop knowledge in ventilator /airway management: what is the evidence?Fry, M. & Kenny, C. 2000, "Ventilators in the ED: the ABC", Australian emergency nursing journal, 3(1) 6-10.

Fry, M. & Ruperto K. A 12 month retrospective study of airway management practices International Emergency Nursing. 2009;17(2):108

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and Practice Can triage nurses stream patients ?

Holdgate A, Morris J, Fry M, Zecevic M. 2007 Accuracy of Triage Nurses in predicting patient disposition. Emergency Medicine, 19, pp. 341-345.

How are mental health patients triaged in an ED?

Fry, M. Brunero, S. 2005 The characteristics and outcomes of mental health patients presenting to an emergency department over a twelve month period. Australian emergency nursing journal. 7(2): 21-25.

De Guio, A., Bolten, C., Fry, M., Hudson, B., Karooz, A., Mellick, N., O'Brien, B., & Scott, L. 1999, training manual for non mental health trained staff to work with mental health patients in hospital emergency departments, NSW Health, Sydney, 1.

How can we improve the time to thrombolysis?

Chan, A., Davidson, P., Scheaffe, S., Fry, M.., Holdgate, A., & Mather, A. The quality improvement process: A mechanism to decrease time delay to thrombolytic therapy in acute myocardial infarction. Australian and New Zealand journal of medicine 1[1], 1. 1998.

What was the mortality rate for one ED?

Fry, M. & Rhodes-Sutton, A. 2005 A retrospective review of adult mortality characteristics of patients presenting to a metropolitan tertiary emergency department. Accident & Emergency Nursing 13(2): 122-125.

How can we improve the ED experience for different multicultural groups?

Fry, M. Ajami, A. Borg A. 2004, Bringing relevant information to diverse groups about emergency department services: The “BRIDGE” Project. Australian Emergency Nursing Journal 7(1): 19-22.

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Research Leaders in Health Services and Practice

We introduce new practices but don‟t think to write it up!

Publishing makes Nursing and Midwifery visible:

Profiles service outcomes

You can provide evidence for system change and debate

Clarifies thought and structure for project/study

Builds capacity and a program of research for your career

Research in teams multidisciplinary collaboration

Interests/disciplines/agenda of team

Builds mutual respect

Nursing and Midwifery transparent and understood

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and Practice

To build/ develop/ explore/ change service you need to

understand culture and social processes

What is the existing culture?

Shared basic assumptions:

beliefs, values, rules, procedures and habits,

and tacit knowledge

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and Practice

Leaders need to examine and understand everyday culture in

order to implement new ways of doing things, and engage with

old or new values.

As a research leader and change agent how do you manage

change?

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Research Leadership in Health

Services and Practice

As leaders you can influence certain things

“circle of influence‟

In the Circle of Concern the focus is on what we need to have in

order to be happy or successful: “I will be happy when my budget is

increased”; “If my boss would change his attitude my team‟s morale

would improve”; “If we had more staff...”.

Operating in the Circle of Influence focus on what they could be or

do: “I could be a better role model”; “I can be more organised”; “I

will take the boss a strategy for change”; “All our service will focus

on solutions rather than problems”.16

Circle of Concern

Circle of Influence


and Practice

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Leading Self

Leading

Upwards

Leading Sideways/ Peers

– internally

Leading Sideways/Peers

- externally

Leading

Downwards


and Practice

1. Lead and manage yourself (50%)

The first and paramount responsibility is to manage self; one's own

integrity, character, ethics, knowledge, wisdom, temperament,

words, and acts.

Without management of self, no one is fit for authority, no matter

how much they acquire.

It is the management of self that should have half of our time and

the best of our ability. And when we do, the ethical, moral, and

spiritual elements of managing self are inescapable.

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and Practice

2. Lead and manage upwards (vertical) (25%)

The second responsibility is to manage those who have authority

over us: nurse managers, supervisors, medical directors, regulators,

ad infinitum.

Without their consent and support, how can we follow conviction,

exercise judgment, use creative ability, achieve constructive results,

or create conditions by which others can do the same?

Managing superiors is essential.

.

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Practice

How do you manage superiors-bosses, regulators, associates, customers?

You can:

understand them

persuade them

motivate them

disturb them, influence them, forgive them

set them an example

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Practice

3. Lead & manage your colleagues (horizontal - peers & those you are not in control of) (20%)

The third responsibility is to manage ones peers-those over whom

we have no authority and who have no authority over us -

associates, competitors, suppliers, customers - the entire

environment, if you will.

Without their support, respect, and confidence, little or nothing can

be accomplished.

Peers can make a small heaven or hell of our life.

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Practice

4. Lead & manage your direct reports (downwards ) (5%)

The fourth responsibility is to manage those over whom we have

authority.

One need only introduce them to the concept, induce them to

practice it, and enjoy the process. If those over whom we have

authority properly manage themselves, manage us, manage their

peers, and replicate the process with those they employ, what is

there to do but see they are properly recognized, rewarded, and stay

out of their way? It is not making better people of others that

management is about. It's about making a better person of self

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and Practice

To achieve change within the existing culture you have:

Early adopters

Sit in the middle

Resisters

As leaders you must influence and manage change to achieve your

goals

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Practice

Everyone is different, with ways of thinking, family background,

priorities, drivers, personality structures, reactions to pressures

Strategies to consider

What drives individuals?

How do they like to take in and process information?

How do they behave under pressure or conflict?

How do you get the best out of them?

What behaviours should you avoid in dealing with them?

Who influences them?

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UTS:NURSING, MIDWIFERY & HEALTH


Research Leaders in Health Services and

Practice

Be prepared to ask how are we doing ?

Can we do better?

Is there new evidence that can support practice change?

Look for opportunities to enhance practice. For example

Government funding –NP, EMU, CIN, aged care funding, chronic

disease, oncology, primary health care

Research Funding- AHW; partnership grants; ARC grants; NHMRC

grants

Identify problems of interest

Critically consider the data- how can we make it better for patients and

staff26


Practice Review general data

Review of KPI benchmarks; Review complaints

Staff issues provide clues for change

Utilise existing resources

University nursing, midwifery and Medical students; Interested allied

and medical staff

Recruit senior staff ; mould junior clinicians

Present the evidence in different forums/ in different ways/

Profile discipline

Fry, M. (2007) Overview of Emergency Nursing in Australasia, in Emergency and

Trauma Nursing, Curtis, K. Ramsden C.,.Friendship, J. ed., Elsevier, Sydney, pp.

2-8.

Fry, M. (2007) Triage, in Emergency and Trauma Nursing, Curtis, K. Ramsden

C.,.Friendship, J, eds., Elsevier, Sydney, pp. 84-91.

Homer, C. & Fry, M. (2007) Gynecological emergencies, in Emergency and

Trauma Nursing, Curtis, K. Ramsden C.,Friendship, J eds., Elsevier Sydney, pp.

502-515. 27


Practice Many types of audits

• Telephone audit: Based on performance indicators DNW

We wanted to explore why patients were leaving the ED prior to treatment being completed

How could we make this work?

• What data collection tool do I need?

• What did I need to collect?

• How do I get the information from patients?

• What did we find?

• Nurses can safely manage and discharge certain patient conditions

• Paediatric area modification

• Pain management in the waiting room

Fry, M. Thompson, J.; Chan, A. 2004,Patients Regularly Leave Emergency Departments

Before Medical Assessment: A Study of Did Not Wait Patients, Medical Profile and

Outcome Characteristics. AENJ 6(2): 21-26.28


Practice Knowledge builds a case for change – NI Panadeine Forte study

Serendipitous DNW findings: waiting room patients were leaving

due to pain

What about those patients that sit in the waiting room in pain?

Computer driven audits

We did an audit using the ED computer software program

How long; what to collect; inclusion and exclusion criteria ???

Developed the audit tool based on available evidence and expertise

Impact: waiting room patients could have NI Panadeine Forte

Nurse initiated pain management agents: now with evidence –Endone

Audit cycle continues

Fry, M. Ryan, J.; and Alexander,N 2004 Prospective Study of Nurse

Initiated Panadeine Forte: Expanding Pain Management in the ED.

Accident & Emergency Nursing 12(3):136-140.

29


Practice

Audits help us to gauge the status of play: How are we doing?

How is pain management going in the ED in 2006?

Medical Records audit of patients that presented in pain

Data tool developed between authors

Manual search of medical records -both researchers reviewed the notes

Audit outcome

Described current practice and patients groups

Women were triaged lower and had a greater wait for analgesic administration

Change practices

Education changes for nurses and MO in the ED

Fry, M. Arendts, G. 2006 Factors Associated with Delay to Narcotic Analgesia in Emergency Departments. The Journal of Pain, 7(9) pp 682-686.

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and Practice

National Audits: National Study NICS –NHMRC

The audit tool was developed in collaboration with the ECoP (n=76)

Audit tool Pilot test in 3 EDs

36 hospitals across Australia

60 patients from each hospital

Change/support/ evidence of practice

Supported the need for all EDs to develop Nurses Initiated pain management

policies

Fry M, Bennetts S, Huckson S. 2011. An Australian Audit of ED Pain

Management Patterns. Journal of Emergency Nursing 37(3): 269-274

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Practice

Examining and exploring practice

• Timeline

• Work load for data collection?

• Who does it impact on?

• Consider as a pilot

Analysis considerations

• How will I analyse the audit?

• How can I get help?32


and Practice

Project Management

Break the audit/project down

Estimate costs

Prepare a project plan/ Gantt Chart/proposal

Communication management

Informal / formal

Reports

Update for department/s

Wrap around a formal research study

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Practice

Often need evidence for change

or

Evidence demands change

Audits

Clarify , explore and articulate everyday practice

Develop research skills

Writing and analytical skills

Builds pride and visibility of work practices, colleagues and team members

Publishing of the audit shares knowledge

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and Practice

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Practice

Find/present the evidence: Develop a line of argument in a proposal

Why is the topic an issue?

What are gaps?

Why is it a problem?

What is known about the problem?

What is uncertain or unknown?

What needs to be better understood or studied?

What does your idea, innovation, change add or contribute to?

What do you want to do?36


:Engagement of all staff and care areas

Staff involvement in selecting topics - concerns

about care can be raised and addressed, may

reduce resistance to change.

Priorities of patients and carers can be very

different to those of clinicians, involve users

where possible, e.g. in planning change.

Healthcare staff with the necessary skills37


Practice

Audits can be a research tool

Rigorous, systematic and published

Multidisciplinary group

Increase understanding of everyday practice

identify potential research questions

ANMC Standard 3

Non-clinical time expectation of outcomes

38


Practice

Nurses Practitioners are well placed to

evaluate services in terms of quality, safety,

effectiveness, appropriateness, consumer

participation, access, equity and efficiency.

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Knowledge Changes Clinicians

Clinicians Change Practice

research leadership in the clinical environment

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